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Critical Review
AAPT Diagnostic Criteria for Fibromyalgia
D1X XLesley M. Arnold,D2X X* D3X XRobert M. Bennett,Dy4X X D5X XLeslie J. Crofford,Dz6X X D7X XLinda E. Dean,Dx8X X
D9X XDaniel J. Clauw,D10X{X D1X XDon L. Goldenberg,D12XjjX D13X XMary-Ann Fitzcharles,D14X X** D15X XEduardo S. Paiva,D16Xyy X
zz xx {{ x
D17X XRoland Staud,D18X X D19X XPiercarlo Sarzi-Puttini,D20X X D21X XDan Buskila,D2X X and D23X XGary J. MacfarlaneD24X X
*
Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
y
Department of Medicine, Oregon Health and Science University, Portland, Oregon
z
Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville,
Tennessee
x
Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, School of Medicine, Medical Sciences and
Nutrition, University of Aberdeen, Scotland, United Kingdom
{
Departments of Anesthesiology, Medicine (Rheumatology), and Psychiatry, University of Michigan Medical School, Ann Arbor,
Michigan
jj
Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, and Departments of Medicine and
Nursing, Oregon Health and Science University, Portland, Oregon
**
Division of Rheumatology, Department of Medicine, McGill University, Montreal, Quebec, Canada
yy
Division of Rheumatology, Department of Medicine, Universidade Federal do Parana, Curitiba, Brazil
zz
Division of Rheumatology, Department of Medicine, University of Florida, Gainesville, Florida
xx
Division of Rheumatology, Department of Medicine, Milan University, Milan, Italy
{{
Department of Medicine, H. Soroka Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
Abstract: Fibromyalgia (FM) is a common chronic pain disorder that presents diagnostic challenges
for clinicians. Several classification, diagnostic and screening criteria have been developed over the
years, but there continues to be a need to develop criteria that reflect the current understanding of
FM and are practical for use by clinicians and researchers. The Analgesic, Anesthetic, and Addiction
Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partner-
ship with the U.S. Food and Drug Administration (FDA) and the American Pain Society (APS) initiated
the ACTTION-APS Pain Taxonomy (AAPT) to develop a diagnostic system that would be clinically use-
ful and consistent across chronic pain disorders. The AAPT established an international FM working
group consisting of clinicians and researchers with expertise in FM to generate core diagnostic criteria
for FM and apply the multidimensional diagnostic framework adopted by AAPT to FM. The process
for developing the AAPT criteria and dimensions included literature reviews and synthesis, consensus
discussions, and analyses of data from large population-based studies conducted in the United King-
dom. The FM working group established a revised diagnosis of FM and identified risk factors, course,
prognosis, and pathophysiology of FM. Future studies will assess the criteria for feasibility, reliability,
and validity. Revisions of the dimensions will also be required as research advances our understand-
ing of FM.
Received May 10, 2018; Revised September 28, 2018; Accepted October has financial conflicts of interest relevant to the issues discussed in this
15, 2018. article. No official endorsement by the FDA should be inferred.
Supplementary data accompanying this article are available online at The authors have no conflicts of interest to declare.
www.jpain.org and www.sciencedirect.com. Address reprint requests to Lesley M. Arnold, M.D., Department of Psy-
Support was provided by the Analgesic, Anesthetic, and Addictions Clin- chiatry and Behavioral Neuroscience, University of Cincinnati College of
ical Trial Translations, Innovations, Opportunities, and Networks public- Medicine, 260 Stetson Street, Suite 3200, Cincinnati, Ohio 45219. E-mail
private partnership with the US Food and Drug Administration (FDA), address: lesley.arnold@uc.edu
which has received contracts, grants, and other revenue for its activities 1526-5900/$36.00
from the FDA, multiple pharmaceutical and device companies, and © 2018 The Author(s). Published by Elsevier Inc. on behalf of the
other sources. A complete list of current Analgesic, Anesthetic, and
Addictions Clinical Trial Translations, Innovations, Opportunities, and American Pain Society This is an open access article under the CC BY-NC-
Networks sponsors is available at http://www.acttion.org/partners. The ND license.
views expressed in this article are those of the authors, none of whom https://doi.org/10.1016/j.jpain.2018.10.008
1
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O
ver many decades, there have been efforts to diagnostic and screening criteria have been developed
develop diagnostic criteria for the condition we over the years.11,16,126,162,187-189,193,197 Early efforts
now recognize as fibromyalgia (FM). The multiple focused on FM as a chronic widespread pain disorder
symptoms and comorbidities associated with FM make it with other associated symptoms.162,197 The American
difficult to diagnose, and FM is still underdiagnosed and College of Rheumatology (ACR) 1990 classification cri-
undertreated.7,34,79 The diagnosis of FM might take teria193 eliminated associated symptoms and focused
>2 years, with patients seeing an average of 3.7 different solely on chronic widespread pain (CWP) (defined as
physicians during that time.34 Many health care providers, pain in the left side of the body, pain in the right side
particularly in primary care, report unclear diagnostic cri- of the body, pain above the waist, pain below the
teria, a lack of confidence in using existing criteria for waist, and axial skeletal pain [cervical spine or anterior
diagnosis, insufficient training or skill in diagnosing FM, chest or thoracic spine or low back]) and tenderness
and a lack of knowledge of treatment options.79 There- (defined as pain on palpation of ≥11 of 18 specific ten-
fore, despite progress in the understanding and manage- der point sites on the body). Although the ACR 1990
ment of FM, there remain barriers in the recognition and criteria helped to advance research studies of FM, the
diagnosis of FM in clinical practice. criteria were not intended for use in clinical practice,
To address problems related to the diagnosis of differ- did not include commonly associated symptoms, and
ent chronic pain disorders, the Analgesic, Anesthetic, and required a tender point exam, which was impractical
Addiction Clinical Trial Translations Innovations Opportu- for use in the clinical setting.74 With the publication of
nities and Networks (ACTTION) public-private partnership the 2010 and 2011 criteria,188,189 the definition of FM
with the U.S. Food and Drug Administration (FDA) and moved from a predominantly chronic pain disorder to
the American Pain Society (APS) initiated the ACTTION- a multi-symptom disorder and eliminated the tender
APS Pain Taxonomy (AAPT) to develop a diagnostic system point exam as a requirement for diagnosis. Although
that would be clinically useful and consistent across the authors of the 2010/2011 criteria re-emphasized
chronic pain disorders. Fillingim et al61 provides more the importance of associated symptoms, there may
information about the rationale and background for the have been too much movement away from chronic
AAPT. In 2013, the AAPT Steering Committee invited L. pain as the core symptom of FM.95 Studies of alterna-
M.A., R.M.B., and L.J.C. to be co-chairs of the Fibromyalgia tive criteria evaluated a variety of associated symptoms
Working Group. The co-chairs subsequently selected inter- along with various definitions of widespread pain in
national FM experts as members of the working group. the diagnosis of FM.11,16 The authors of the revised
The goal of the Fibromyalgia Working Group was to apply 2016 criteria187 addressed the problem with the 2010/
the multidimensional diagnostic framework adopted by 2011 criteria regarding misclassification of patients
AAPT to FM and evaluate new approaches to the diagno- who did not have generalized pain,57 which occurred
sis of FM that might improve the recognition of FM in clin- because the 2010/2011 criteria do not consider the spa-
ical practice. Briefly, in the AAPT taxonomy, there are 5 tial distribution of painful sites. The 2016 criteria now
dimensions: dimension 1: core diagnostic criteria; dimen- require that patients have pain in 4 of 5 regions, called
sion 2: common features; dimension 3: common medical “generalized pain” to distinguish it from the 1990 defi-
co-morbidities; dimension 4: neurobiological, psychoso- nition of “widespread pain.” Even though there are
cial, and functional consequences; and dimension 5: puta- different definitions of widespread pain and associated
tive neurobiological and psychosocial mechanisms, risk symptoms, most of the previous FM criteria appear to
factors, and protective factors.61 identify a similar group of patients most clinicians
As part of the AAPT process, the Fibromyalgia Working would agree have FM.
Group members held in-person meetings, teleconfer- Based on the review of existing criteria, the consensus
ences, and email communications to review the literature of the Fibromyalgia Working Group was to devise core
on FM symptoms and diagnostic criteria and establish diagnostic criteria (dimension 1) that would reflect the
consensus on the approach to FM diagnosis. This article current understanding of FM and be practical for use by
details the development of the dimensions for FM. clinicians and to provide a basis for clinical trial inclusion
and exclusion criteria. The multidimensional diagnostic
framework of the AAPT allowed the group to identify
Dimension 1 the core symptoms of FM and include other associated
symptoms and signs in dimension 2. The group members
Core Diagnostic Criteria agreed that dimension 1 would include only a core set
There have been many efforts to improve the identi- of diagnostic symptoms, and that signs such as tender
fication of patients with FM, and several classifications, points would be relegated to dimension 2.
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NOTE. The presence of another pain disorder or related symptoms does not rule out a diagnosis of
FM. However, a clinical assessment is recommended to evaluate for any condition that could fully
account for the patient’s symptoms or contribute to the severity of the symptoms.
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least 6 of 9 pain sites are required along with fatigue or such as statins, aromatase inhibitors, bisphosphonates,
sleep problems. Fatigue is defined as physical or mental and opioids (ie, opioid-induced hyperalgesia). However,
fatigue judged as at least moderate severity by the these conditions and many others (eg, rheumatoid arthri-
health care professional. Physical fatigue may manifest tis, osteoarthritis, systemic lupus erythematosus [SLE], spi-
as a complaint of physical exhaustion after physical nal stenosis, neuropathies, Ehlers Danlos syndrome,51
activity, including an inability to function within normal sleep disorders such as sleep apnea, and mood and anxi-
limits for activities that constitute normal daily activities ety disorders121) also co-occur in patients with FM. The
and the requirement for rest periods after activity. Sleep clinician must determine the possible contribution of var-
problems are defined as difficulty falling or staying ious disorders to the patient’s presentation. The presence
asleep, frequent awakening that is disturbing during a of other disorders does not necessarily exclude a diagno-
sleep period, or feeling unrefreshed after sleep. These sis of FM, and all disorders will need clinical attention.
symptoms must be assessed as at least moderate severity Table 2 summarizes some of the key medical disorders
by the health care professional. In assessing the severity considered in the differential diagnosis of FM that
of fatigue and sleep problems, the clinician may use require additional assessment, tests, and specific treat-
multiple sources of information, including patient his- ment. A description of several differentiating signs and
tory and exam, as well as self-reported questionnaires symptoms are provided in the table, but a detailed
or other corroborating data. review of the diagnostic tests for each medical disorder is
beyond the scope of this article.
In general, extensive laboratory testing is not necessary
Differential Diagnosis to diagnose FM.7 Screening laboratory tests are some-
These new criteria for FM recommend that clinicians times obtained to evaluate other possible causes of
evaluate for the presence of other disorders so that symptoms or signs. These tests include erythrocyte sedi-
appropriate treatments can be initiated. This can be chal- mentation rate and/or C-reactive protein, complete
lenging in clinical practice because comorbid disorders, blood count, comprehensive metabolic panel, and thy-
including other chronic pain disorders, are common in roid function test. Routine testing for rheumatoid factor
patients with FM.7 Several disorders can mimic FM, such or antinuclear antibodies to diagnose FM is not recom-
as hypothyroidism and inflammatory rheumatic diseases. mended unless the patient has signs or symptoms
In addition, some medications may contribute to pain, suggesting an autoimmune disorder, or if initial
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Rheumatologic
Rheumatoid arthritis Predominant joint pain, symmetric joint swelling, joint line tenderness, morning stiffness >1 hour
Systemic lupus erythematosus Multisystem involvement, joint/muscle pain, rash, photosensitivity, fever
Polyarticular osteoarthritis Joint stiffness, crepitus, multiple painful joints
Polymyalgia rheumatica Proximal shoulder and hip girdle pain, weakness, stiffness, more common in the elderly
Polymyositis or other myopathies Symmetric, proximal muscle weakness and pain
Spondyloarthropathy Localization of spinal pain to specific sites in the neck, mid-thoracic, anterior chest wall, or lumbar regions,
objective limitation of spinal mobility due to pain and stiffness
Osteomalacia Diffuse bone pain, fractures, proximal myopathy with muscle weakness
Neurologic
Neuropathy Shooting or burning pain, tingling, numbness, weakness
Multiple sclerosis Visual changes (unilateral partial or complete loss, double vision), ascending numbness in a leg or bandlike
truncal numbness, slurred speech (dysarthria)
Infectious
Lyme disease Rash, arthritis or arthralgia, occurs in areas of endemic disease
Hepatitis Right upper quadrant pain, nausea, decreased appetite
Endocrine
Hyperparathyroidism Increased thirst and urination, kidney stones, nausea/vomiting, decreased appetite, thinning bones,
constipation
Cushing syndrome Hypertension, diabetes, hirsutism, moon facies, weight gain
Addison disease Postural hypotension, nausea, vomiting, skin pigmentation, weight loss
Hypothyroidism Cold intolerance, mental slowing, constipation, weight gain, hair loss
inflammatory indices are abnormal (recognizing that neuropsychological testing may be required to delin-
some patients with rheumatoid arthritis or SLE may have eate the extent of cognitive dysfunction.163 In brain
normal erythrocyte sedimentation rate and/or C-reactive functional magnetic resonance imaging (fMRI) stud-
protein values). Depending on symptoms, medical history ies,71,170 FM patients showed lower activation in the
and physical exam, other tests such as ferritin, iron-bind- inhibition and attention networks and increased activa-
ing capacity and percentage of saturation, and vitamin tion in other areas. Because inhibition and pain percep-
B12 and vitamin D levels may be indicated. tion may use overlapping networks, resources taken up
by pain processing may be unavailable for other
processes.71
Dimension 2 Musculoskeletal stiffness is experienced, in varying
degrees, by all FM patients.17 Interestingly, stiffness in
Common Features FM patients is difficult to distinguish from the stiffness in
Features that are not included in dimension 1 but may conditions such as rheumatoid arthritis, polymyalgia
be used to support a diagnosis of FM are described below. rheumatica, and ankylosing spondylitis. FM-related stiff-
Tenderness, defined as a generalized sensitivity of soft ness, like that described in these other conditions, is typi-
tissues and muscles to pressure that would not normally cally more severe in the early morning and improves as
be expected to cause pain, is a universal complaint and in the day goes on.86 However, unlike these other condi-
the 1990 ACR criteria was codified by the “tender point” tions, it is not responsive to corticosteroids.37 This feature
examination.193 Although the tender point evaluation is only used in the 2014 Bennett et al criteria and was
has been eliminated from the more recent criteria, with ranked fifth in importance as a diagnostic question.16
the exception of the 2012 FM screen,11,126 the symptom Environmental sensitivity or hypervigilance, manifesting
of “tenderness to touch” is included in the 2014 Bennett as intolerance to bright lights, loud noises, perfumes and
et al criteria16 and the 2012 FM screen11,126; this question cold, is a common complaint of FM patients. It is probably
was ranked third in importance as a diagnostic question a reflection of central sensitization.54,142 A recent study has
in the 2014 Bennett et al criteria.16 A tender point exam, provided clues as to how sensitivity to bright lights modu-
either as part of the 1990 ACR criteria193 or an abbrevi- lates brain connectivity, such that previously innocuous
ated version,11,126 may provide valuable information to inputs are experienced as being painful.125 This feature is
the clinician about the overall status of the patient’s con- only used in the 2014 Bennett et al criteria16 and was
dition74 and support the diagnosis of FM. ranked second in importance as a diagnostic question.
Dyscognition (eg, trouble concentrating, forgetful-
ness, and disorganized or slow thinking) is increasingly
recognized as a major feature of FM, with dysfunction Epidemiology
being seen in working memory and executive func- The prevalence of FM varies from .5 to 12%, depend-
tion.70 Self-reported questionnaires are useful to screen ing on the population sampled and the method of ascer-
for dyscognition in patients with FM, but full tainment.104,128,138,144,158,177,182,192 Females outnumber
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